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Providers for Zip Code 54840

Obamacare 2017 Marketplace Rates For Burnett County, Wisconsin

Friday, December 9th, 2016

Click for Grantsburg, Wisconsin Forecast

Obamacare Providers, Plans and 2017 Rates for Burnett County

The health insurance rates listed below are for calendar year 2017.

2017 Rates and Providers

(click here for 2014)

(click here for 2015)

(click here for 2016)

This page gives you an overview of the rates for individual and family health insurance plans available from HealthCare.gov, the marketplace for Burnett County, Wisconsin.

Currently, there are 37 plans offered in Burnett County.

Below, you’ll find a summary of plans and rates for each of these providers. This chart is designed to give you a preview of your health insurance options. For detailed information on available subsidies to make your coverage affordable, you must complete an application at HealthCare.gov or contact the provider directly.

 

The table below shows premiums for the following scenarios:

  • Individual
  • Couple
  • Couple with 1 2 or 3 children
  • Individual with 1 2 or 3 children
  • A child alone

Each scenario is covered for age

  • Age 21, 30, 40, 50
  • Age 60 (Individual and Couple only)

 

Note: If you are over 65, you qualify for Medicare. Click here to see listings of 2017 Medicare Advantage plans for Burnett County

 

For each plan, there are links that go to the insurance provider's website in a new window. You can find links to:

  • a summary of plan benefits and costs,
  • a plan brochure, and
  • a "Provider Directory" -- where you can find out which doctors and hospitals in the Grantsburg, WI area accept this insurance coverage as within the plan's "network".

‡Source: HealthCare.gov has released sample rates for all counties in those states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Burnett County here.

HealthPartners Insurance Company

Local: 1-952-883-5900 | Toll Free: 1-855-813-3887

TTY: 1-952-883-6060

Plan: (PPO) Atlas Individual $500 w/Copay Gold

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-813-3887 - Provider Directory for This Plan: (HealthPartners Insurance Company)

Deductible: Individual: $500 : Family: $1,000
Out of Pocket Maximum per year: Individual: $7,000 : Family: $14,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$510.21
$579.09
$652.05
$911.24
$1384.71
$1020.42
$1158.18
$1304.10
$1822.48
$2769.42
$1344.40
$1482.16
$1628.08
$2146.46
$1668.38
$1806.14
$1952.06
$2470.44
$1992.36
$2130.12
$2276.04
$2794.42
$834.19
$903.07
$976.03
$1235.22
$1158.17
$1227.05
$1300.01
$1559.20
$1482.15
$1551.03
$1623.99
$1883.18
$323.98

Plan: (PPO) Atlas Individual $2200 Plus Silver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-813-3887 - Provider Directory for This Plan: (HealthPartners Insurance Company)

Deductible: Individual: $2,200 : Family: $4,400
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$411.08
$466.58
$525.36
$734.19
$1115.67
$822.16
$933.16
$1050.72
$1468.38
$2231.34
$1083.20
$1194.20
$1311.76
$1729.42
$1344.24
$1455.24
$1572.80
$1990.46
$1605.28
$1716.28
$1833.84
$2251.50
$672.12
$727.62
$786.40
$995.23
$933.16
$988.66
$1047.44
$1256.27
$1194.20
$1249.70
$1308.48
$1517.31
$261.04

Plan: (PPO) Atlas Individual $3500 Plus Silver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-813-3887 - Provider Directory for This Plan: (HealthPartners Insurance Company)

Deductible: Individual: $3,500 : Family: $7,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$429.20
$487.14
$548.52
$766.55
$1164.85
$858.40
$974.28
$1097.04
$1533.10
$2329.70
$1130.94
$1246.82
$1369.58
$1805.64
$1403.48
$1519.36
$1642.12
$2078.18
$1676.02
$1791.90
$1914.66
$2350.72
$701.74
$759.68
$821.06
$1039.09
$974.28
$1032.22
$1093.60
$1311.63
$1246.82
$1304.76
$1366.14
$1584.17
$272.54

Plan: (PPO) Atlas Individual $6850 Plus Bronze

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-813-3887 - Provider Directory for This Plan: (HealthPartners Insurance Company)

Deductible: Individual: $6,850 : Family: $13,700
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$343.81
$390.22
$439.39
$614.04
$933.10
$687.62
$780.44
$878.78
$1228.08
$1866.20
$905.94
$998.76
$1097.10
$1446.40
$1124.26
$1217.08
$1315.42
$1664.72
$1342.58
$1435.40
$1533.74
$1883.04
$562.13
$608.54
$657.71
$832.36
$780.45
$826.86
$876.03
$1050.68
$998.77
$1045.18
$1094.35
$1269.00
$218.32

Plan: (PPO) Atlas Individual $7150 Bronze

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-813-3887 - Provider Directory for This Plan: (HealthPartners Insurance Company)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$325.78
$369.76
$416.35
$581.84
$884.17
$651.56
$739.52
$832.70
$1163.68
$1768.34
$858.43
$946.39
$1039.57
$1370.55
$1065.30
$1153.26
$1246.44
$1577.42
$1272.17
$1360.13
$1453.31
$1784.29
$532.65
$576.63
$623.22
$788.71
$739.52
$783.50
$830.09
$995.58
$946.39
$990.37
$1036.96
$1202.45
$206.87

Plan: (PPO) Atlas Individual $7150 Catastrophic

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-813-3887 - Provider Directory for This Plan: (HealthPartners Insurance Company)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$246.29
$279.54
$314.76
$439.87
$668.43
$492.58
$559.08
$629.52
$879.74
$1336.86
$648.97
$715.47
$785.91
$1036.13
$805.36
$871.86
$942.30
$1192.52
$961.75
$1028.25
$1098.69
$1348.91
$402.68
$435.93
$471.15
$596.26
$559.07
$592.32
$627.54
$752.65
$715.46
$748.71
$783.93
$909.04

Plan: (PPO) Atlas Individual $3000 HSA Silver

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-813-3887 - Provider Directory for This Plan: (HealthPartners Insurance Company)

Deductible: Individual: $3,000 : Family: $6,000
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$390.18
$442.85
$498.65
$696.86
$1058.95
$780.36
$885.70
$997.30
$1393.72
$2117.90
$1028.12
$1133.46
$1245.06
$1641.48
$1275.88
$1381.22
$1492.82
$1889.24
$1523.64
$1628.98
$1740.58
$2137.00
$637.94
$690.61
$746.41
$944.62
$885.70
$938.37
$994.17
$1192.38
$1133.46
$1186.13
$1241.93
$1440.14
$247.76

Plan: (PPO) Atlas Individual $6550 HSA Bronze

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-855-813-3887 - Provider Directory for This Plan: (HealthPartners Insurance Company)

Deductible: Individual: $6,550 : Family: $13,100
Out of Pocket Maximum per year: Individual: $6,550 : Family: $13,100

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$339.67
$385.53
$434.10
$606.65
$921.86
$679.34
$771.06
$868.20
$1213.30
$1843.72
$895.03
$986.75
$1083.89
$1428.99
$1110.72
$1202.44
$1299.58
$1644.68
$1326.41
$1418.13
$1515.27
$1860.37
$555.36
$601.22
$649.79
$822.34
$771.05
$816.91
$865.48
$1038.03
$986.74
$1032.60
$1081.17
$1253.72
$215.69

Security Health Plan of Wisconsin, Inc.

Local: 1-715-221-9258 x19258 | Toll Free: 1-844-293-9624

TTY: 1-877-727-2232

Plan: (HMO) Classic $1,500 - 20%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$486.06
$551.67
$621.17
$868.09
$1319.15
$972.12
$1103.34
$1242.34
$1736.18
$2638.30
$1280.76
$1411.98
$1550.98
$2044.82
$1589.40
$1720.62
$1859.62
$2353.46
$1898.04
$2029.26
$2168.26
$2662.10
$794.70
$860.31
$929.81
$1176.73
$1103.34
$1168.95
$1238.45
$1485.37
$1411.98
$1477.59
$1547.09
$1794.01
$308.64

Plan: (HMO) Classic $3,750 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $3,750 : Family: $7,500
Out of Pocket Maximum per year: Individual: $3,750 : Family: $7,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$428.46
$486.29
$547.56
$765.21
$1162.81
$856.92
$972.58
$1095.12
$1530.42
$2325.62
$1128.98
$1244.64
$1367.18
$1802.48
$1401.04
$1516.70
$1639.24
$2074.54
$1673.10
$1788.76
$1911.30
$2346.60
$700.52
$758.35
$819.62
$1037.27
$972.58
$1030.41
$1091.68
$1309.33
$1244.64
$1302.47
$1363.74
$1581.39
$272.06

Plan: (HMO) Classic $2,500 - 20%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$402.89
$457.27
$514.89
$719.55
$1093.43
$805.78
$914.54
$1029.78
$1439.10
$2186.86
$1061.61
$1170.37
$1285.61
$1694.93
$1317.44
$1426.20
$1541.44
$1950.76
$1573.27
$1682.03
$1797.27
$2206.59
$658.72
$713.10
$770.72
$975.38
$914.55
$968.93
$1026.55
$1231.21
$1170.38
$1224.76
$1282.38
$1487.04
$255.83

Plan: (HMO) Classic $2,000 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$402.21
$456.50
$514.02
$718.33
$1091.58
$804.42
$913.00
$1028.04
$1436.66
$2183.16
$1059.82
$1168.40
$1283.44
$1692.06
$1315.22
$1423.80
$1538.84
$1947.46
$1570.62
$1679.20
$1794.24
$2202.86
$657.61
$711.90
$769.42
$973.73
$913.01
$967.30
$1024.82
$1229.13
$1168.41
$1222.70
$1280.22
$1484.53
$255.40

Plan: (HMO) Classic $6,000 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$340.86
$386.86
$435.61
$608.76
$925.07
$681.72
$773.72
$871.22
$1217.52
$1850.14
$898.16
$990.16
$1087.66
$1433.96
$1114.60
$1206.60
$1304.10
$1650.40
$1331.04
$1423.04
$1520.54
$1866.84
$557.30
$603.30
$652.05
$825.20
$773.74
$819.74
$868.49
$1041.64
$990.18
$1036.18
$1084.93
$1258.08
$216.44

Plan: (HMO) Classic $5,500 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$351.09
$398.47
$448.67
$627.02
$952.82
$702.18
$796.94
$897.34
$1254.04
$1905.64
$925.11
$1019.87
$1120.27
$1476.97
$1148.04
$1242.80
$1343.20
$1699.90
$1370.97
$1465.73
$1566.13
$1922.83
$574.02
$621.40
$671.60
$849.95
$796.95
$844.33
$894.53
$1072.88
$1019.88
$1067.26
$1117.46
$1295.81
$222.93

Plan: (HMO) Classic Protection

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$231.79
$263.07
$296.21
$413.96
$629.05
$463.58
$526.14
$592.42
$827.92
$1258.10
$610.76
$673.32
$739.60
$975.10
$757.94
$820.50
$886.78
$1122.28
$905.12
$967.68
$1033.96
$1269.46
$378.97
$410.25
$443.39
$561.14
$526.15
$557.43
$590.57
$708.32
$673.33
$704.61
$737.75
$855.50
$147.18

Plan: (HMO) Classic $4,500 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$399.15
$453.02
$510.09
$712.86
$1083.25
$798.30
$906.04
$1020.18
$1425.72
$2166.50
$1051.75
$1159.49
$1273.63
$1679.17
$1305.20
$1412.94
$1527.08
$1932.62
$1558.65
$1666.39
$1780.53
$2186.07
$652.60
$706.47
$763.54
$966.31
$906.05
$959.92
$1016.99
$1219.76
$1159.50
$1213.37
$1270.44
$1473.21
$253.45

Plan: (HMO) Classic $6,500 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$326.20
$370.23
$416.88
$582.58
$885.29
$652.40
$740.46
$833.76
$1165.16
$1770.58
$859.53
$947.59
$1040.89
$1372.29
$1066.66
$1154.72
$1248.02
$1579.42
$1273.79
$1361.85
$1455.15
$1786.55
$533.33
$577.36
$624.01
$789.71
$740.46
$784.49
$831.14
$996.84
$947.59
$991.62
$1038.27
$1203.97
$207.13

Plan: (HMO) Classic $7,150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$315.98
$358.62
$403.81
$564.32
$857.54
$631.96
$717.24
$807.62
$1128.64
$1715.08
$832.60
$917.88
$1008.26
$1329.28
$1033.24
$1118.52
$1208.90
$1529.92
$1233.88
$1319.16
$1409.54
$1730.56
$516.62
$559.26
$604.45
$764.96
$717.26
$759.90
$805.09
$965.60
$917.90
$960.54
$1005.73
$1166.24
$200.64

Plan: (EPO) Select $6,500 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $6,500 : Family: $13,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$266.55
$302.53
$340.64
$476.05
$723.40
$533.10
$605.06
$681.28
$952.10
$1446.80
$702.36
$774.32
$850.54
$1121.36
$871.62
$943.58
$1019.80
$1290.62
$1040.88
$1112.84
$1189.06
$1459.88
$435.81
$471.79
$509.90
$645.31
$605.07
$641.05
$679.16
$814.57
$774.33
$810.31
$848.42
$983.83
$169.26

Plan: (HMO) Classic $5,500 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$384.49
$436.38
$491.36
$686.68
$1043.48
$768.98
$872.76
$982.72
$1373.36
$2086.96
$1013.12
$1116.90
$1226.86
$1617.50
$1257.26
$1361.04
$1471.00
$1861.64
$1501.40
$1605.18
$1715.14
$2105.78
$628.63
$680.52
$735.50
$930.82
$872.77
$924.66
$979.64
$1174.96
$1116.91
$1168.80
$1223.78
$1419.10
$244.14

Plan: (EPO) Select $1,500 - 20%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $1,500 : Family: $3,000
Out of Pocket Maximum per year: Individual: $3,500 : Family: $7,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$397.10
$450.70
$507.48
$709.20
$1077.70
$794.20
$901.40
$1014.96
$1418.40
$2155.40
$1046.35
$1153.55
$1267.11
$1670.55
$1298.50
$1405.70
$1519.26
$1922.70
$1550.65
$1657.85
$1771.41
$2174.85
$649.25
$702.85
$759.63
$961.35
$901.40
$955.00
$1011.78
$1213.50
$1153.55
$1207.15
$1263.93
$1465.65
$252.15

Plan: (EPO) Select $3,750 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $3,750 : Family: $7,500
Out of Pocket Maximum per year: Individual: $3,750 : Family: $7,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$350.06
$397.31
$447.37
$625.19
$950.04
$700.12
$794.62
$894.74
$1250.38
$1900.08
$922.40
$1016.90
$1117.02
$1472.66
$1144.68
$1239.18
$1339.30
$1694.94
$1366.96
$1461.46
$1561.58
$1917.22
$572.34
$619.59
$669.65
$847.47
$794.62
$841.87
$891.93
$1069.75
$1016.90
$1064.15
$1114.21
$1292.03
$222.28

Plan: (EPO) Select $2,500 - 20%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,500 : Family: $5,000
Out of Pocket Maximum per year: Individual: $6,850 : Family: $13,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$329.27
$373.71
$420.80
$588.06
$893.61
$658.54
$747.42
$841.60
$1176.12
$1787.22
$867.62
$956.50
$1050.68
$1385.20
$1076.70
$1165.58
$1259.76
$1594.28
$1285.78
$1374.66
$1468.84
$1803.36
$538.35
$582.79
$629.88
$797.14
$747.43
$791.87
$838.96
$1006.22
$956.51
$1000.95
$1048.04
$1215.30
$209.08

Plan: (EPO) Select $7,150

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$258.37
$293.24
$330.19
$461.44
$701.20
$516.74
$586.48
$660.38
$922.88
$1402.40
$680.80
$750.54
$824.44
$1086.94
$844.86
$914.60
$988.50
$1251.00
$1008.92
$1078.66
$1152.56
$1415.06
$422.43
$457.30
$494.25
$625.50
$586.49
$621.36
$658.31
$789.56
$750.55
$785.42
$822.37
$953.62
$164.06

Plan: (EPO) Select $2,000 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $2,000 : Family: $4,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$328.59
$372.94
$419.92
$586.84
$891.76
$657.18
$745.88
$839.84
$1173.68
$1783.52
$865.83
$954.53
$1048.49
$1382.33
$1074.48
$1163.18
$1257.14
$1590.98
$1283.13
$1371.83
$1465.79
$1799.63
$537.24
$581.59
$628.57
$795.49
$745.89
$790.24
$837.22
$1004.14
$954.54
$998.89
$1045.87
$1212.79
$208.65

Plan: (EPO) Select $6,000 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $6,000 : Family: $12,000
Out of Pocket Maximum per year: Individual: $6,350 : Family: $12,700

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$278.48
$316.07
$355.89
$497.36
$755.78
$556.96
$632.14
$711.78
$994.72
$1511.56
$733.79
$808.97
$888.61
$1171.55
$910.62
$985.80
$1065.44
$1348.38
$1087.45
$1162.63
$1242.27
$1525.21
$455.31
$492.90
$532.72
$674.19
$632.14
$669.73
$709.55
$851.02
$808.97
$846.56
$886.38
$1027.85
$176.83

Plan: (EPO) Select $5,500 HDHP

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $6,500 : Family: $13,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$287.01
$325.74
$366.78
$512.57
$778.91
$574.02
$651.48
$733.56
$1025.14
$1557.82
$756.26
$833.72
$915.80
$1207.38
$938.50
$1015.96
$1098.04
$1389.62
$1120.74
$1198.20
$1280.28
$1571.86
$469.25
$507.98
$549.02
$694.81
$651.49
$690.22
$731.26
$877.05
$833.73
$872.46
$913.50
$1059.29
$182.24

Plan: (EPO) Select Protection

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$189.18
$214.71
$241.76
$337.86
$513.41
$378.36
$429.42
$483.52
$675.72
$1026.82
$498.48
$549.54
$603.64
$795.84
$618.60
$669.66
$723.76
$915.96
$738.72
$789.78
$843.88
$1036.08
$309.30
$334.83
$361.88
$457.98
$429.42
$454.95
$482.00
$578.10
$549.54
$575.07
$602.12
$698.22
$120.12

Plan: (EPO) Select $4,500 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $4,500 : Family: $9,000
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$326.20
$370.23
$416.88
$582.58
$885.29
$652.40
$740.46
$833.76
$1165.16
$1770.58
$859.53
$947.59
$1040.89
$1372.29
$1066.66
$1154.72
$1248.02
$1579.42
$1273.79
$1361.85
$1455.15
$1786.55
$533.33
$577.36
$624.01
$789.71
$740.46
$784.49
$831.14
$996.84
$947.59
$991.62
$1038.27
$1203.97
$207.13

Plan: (EPO) Select $5,500 - 30%

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-844-293-9624 - Provider Directory for This Plan: (Security Health Plan of Wisconsin, Inc.)

Deductible: Individual: $5,500 : Family: $11,000
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$314.27
$356.69
$401.63
$561.27
$852.91
$628.54
$713.38
$803.26
$1122.54
$1705.82
$828.10
$912.94
$1002.82
$1322.10
$1027.66
$1112.50
$1202.38
$1521.66
$1227.22
$1312.06
$1401.94
$1721.22
$513.83
$556.25
$601.19
$760.83
$713.39
$755.81
$800.75
$960.39
$912.95
$955.37
$1000.31
$1159.95
$199.56

Medica Health Plans of Wisconsin

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211

TTY: 1-800-855-2880

Plan: (PPO) Medica Individual Choice Gold Copay

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-592-8211 - Provider Directory for This Plan: (Medica Health Plans of Wisconsin)

Deductible: Individual: $300 : Family: $900
Out of Pocket Maximum per year: Individual: $5,000 : Family: $10,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$443.29
$503.12
$566.51
$791.70
$1203.06
$886.58
$1006.24
$1133.02
$1583.40
$2406.12
$1168.06
$1287.72
$1414.50
$1864.88
$1449.54
$1569.20
$1695.98
$2146.36
$1731.02
$1850.68
$1977.46
$2427.84
$724.77
$784.60
$847.99
$1073.18
$1006.25
$1066.08
$1129.47
$1354.66
$1287.73
$1347.56
$1410.95
$1636.14
$281.48

Plan: (PPO) Medica Individual Choice Silver Copay

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-592-8211 - Provider Directory for This Plan: (Medica Health Plans of Wisconsin)

Deductible: Individual: $2,600 : Family: $7,800
Out of Pocket Maximum per year: Individual: $5,750 : Family: $11,500

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$387.13
$439.38
$494.73
$691.39
$1050.63
$774.26
$878.76
$989.46
$1382.78
$2101.26
$1020.08
$1124.58
$1235.28
$1628.60
$1265.90
$1370.40
$1481.10
$1874.42
$1511.72
$1616.22
$1726.92
$2120.24
$632.95
$685.20
$740.55
$937.21
$878.77
$931.02
$986.37
$1183.03
$1124.59
$1176.84
$1232.19
$1428.85
$245.82

Plan: (PPO) Medica Individual Choice Bronze Copay

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-592-8211 - Provider Directory for This Plan: (Medica Health Plans of Wisconsin)

Deductible: Individual: $6,850 : Family: $13,700
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$343.51
$389.87
$438.99
$613.49
$932.25
$687.02
$779.74
$877.98
$1226.98
$1864.50
$905.14
$997.86
$1096.10
$1445.10
$1123.26
$1215.98
$1314.22
$1663.22
$1341.38
$1434.10
$1532.34
$1881.34
$561.63
$607.99
$657.11
$831.61
$779.75
$826.11
$875.23
$1049.73
$997.87
$1044.23
$1093.35
$1267.85
$218.12

Plan: (PPO) Medica Individual Choice Silver H S A

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-592-8211 - Provider Directory for This Plan: (Medica Health Plans of Wisconsin)

Deductible: Individual: $1,300 : Family: $3,900
Out of Pocket Maximum per year: Individual: $5,500 : Family: $11,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Silver 21
30
40
50
60
$380.70
$432.08
$486.52
$679.91
$1033.19
$761.40
$864.16
$973.04
$1359.82
$2066.38
$1003.14
$1105.90
$1214.78
$1601.56
$1244.88
$1347.64
$1456.52
$1843.30
$1486.62
$1589.38
$1698.26
$2085.04
$622.44
$673.82
$728.26
$921.65
$864.18
$915.56
$970.00
$1163.39
$1105.92
$1157.30
$1211.74
$1405.13
$241.74

Plan: (PPO) Medica Individual Choice Bronze H S A

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-592-8211 - Provider Directory for This Plan: (Medica Health Plans of Wisconsin)

Deductible: Individual: $6,400 : Family: $12,800
Out of Pocket Maximum per year: Individual: $6,400 : Family: $12,800

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Bronze 21
30
40
50
60
$330.92
$375.58
$422.90
$591.00
$898.08
$661.84
$751.16
$845.80
$1182.00
$1796.16
$871.97
$961.29
$1055.93
$1392.13
$1082.10
$1171.42
$1266.06
$1602.26
$1292.23
$1381.55
$1476.19
$1812.39
$541.05
$585.71
$633.03
$801.13
$751.18
$795.84
$843.16
$1011.26
$961.31
$1005.97
$1053.29
$1221.39
$210.13

Plan: (PPO) Medica Individual Choice Catastrophic

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-592-8211 - Provider Directory for This Plan: (Medica Health Plans of Wisconsin)

Deductible: Individual: $7,150 : Family: $14,300
Out of Pocket Maximum per year: Individual: $7,150 : Family: $14,300

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Catastrophic 21
30
40
50
60
$212.61
$241.30
$271.70
$379.70
$576.99
$425.22
$482.60
$543.40
$759.40
$1153.98
$560.22
$617.60
$678.40
$894.40
$695.22
$752.60
$813.40
$1029.40
$830.22
$887.60
$948.40
$1164.40
$347.61
$376.30
$406.70
$514.70
$482.61
$511.30
$541.70
$649.70
$617.61
$646.30
$676.70
$784.70
$135.00

Plan: (PPO) Medica Individual Choice Gold Copay Plus

Summary of Benefits and Coverage - Plan Brochure - Customer Service Phone: 1-888-592-8211 - Provider Directory for This Plan: (Medica Health Plans of Wisconsin)

Deductible: Individual: $1,000 : Family: $3,000
Out of Pocket Maximum per year: Individual: $4,000 : Family: $8,000

Monthly Premiums:

Metal level Age Individual
Couple
Couple
w 1 Kid
Couple
w 2 Kids
Couple
w3+Kids
Single
w 1 Kid
Single
w 2 Kids
Single
w3+Kids
Child
any age
Gold 21
30
40
50
60
$480.88
$545.79
$614.55
$858.83
$1305.08
$961.76
$1091.58
$1229.10
$1717.66
$2610.16
$1267.11
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